Amy E. Krambeck, M.D., with the Department of Urology discusses the advantages and outcomes for holmium laser enucleation of the prostate (HoLEP) performed for benign prostatic hyperplasia (BPH).
HoLEP was first performed in the United States in 1998; however, has been slow to gain widespread acceptance due to its steep learning curve. The procedure has been shown to have superior short and long-term outcomes to transurethral resection of the prostate (TURP) and suprapubic prostatectomy.
Benefits of the HoLEP procedure include complete removal of the adenoma to the level of the prostate resulting in a less than 2% retreatment rate, lack of surgical incision, and no effect on erectile function. Furthermore, HoLEP can be performed on prostate glands of any size. HoLEP is performed as an outpatient procedure or as a 23 hour observation and the urethral catheter is removed the day after surgery. All patients experience hematuria for 1 to 2 weeks post procedure, but the need for blood transfusion is 1%. Transient urinary incontinence is common, but permanent incontinence at 1 year post procedure occurs in approximately 1% of patients. We are now offering HoLEP at Mayo Clinic in Arizona and Minnesota.
How much (range) of the prostate is removed by HoLEP?
To what degree are functions performed by the prostate compromised?
Are there further detailed descriptions of the procedure?
Dr. Krambeck responds:
How much (range) of the prostate is removed by HoLEP? 80-90% of the prostate is removed with this technique.
To what degree are functions performed by the prostate compromised? Prostate function, which is liquifaction of the seminal fluid, is preserved. Patients do develop retrograde ejaculation after the procedure, however, so the semen is deposited in the bladder instead of out the urethra.
Are there further detailed descriptions of the procedure? There are multiple published articles on the procedure as well as many videos on the internet.
I am considering HoLEP surgery. Are there any doctors or hospitals near Tulsa OK that perform this type of surgery?
my prostate is 130g. Is that too large for the HoLep procedure?
There is no size limit for HoLEP. A prostate of 130 grams is ideal for the procedure.
Question. Is HoLep an option for patients with prostate cancer?
Dr. Krambeck responds: HoLEP is not a treatment option for prostate cancer since it does not remove the entire prostate. The purpose of the procedure is to remove the obstructing prostate tissue to help with urination, not the treatment of cancer.
I am a 59 yr old physician who recently had a HoLEP after having obstructive symptoms for over 10 years. I had a very large prostate and my local urologist recommended a suprapubic prostatectomy. After much research, I elected to undergo a HoLEP by Dr. James Lingeman at Indiana University, who has not done an open prostatectomy for BPH in many years. All I can say is that I wish I had had this procedure a long time ago. The results are amazing with a very quick recovery and minimal symptoms of dysuria and urgency, which will no doubt resolve over the ensuing weeks. It truly is unfortunate that HoLEP has not “caught on” in this country due to it’s steep learning curve (meaning most practicing urologists do not want to take the time, effort and money to learn it). I also understand that many hospitals do not want to make the capital investment because it does not fit the business model of having high chargeable disposables, as do other minimally invasive surgical procedures. Shame on them and shame on urologists who do not embrace this procedure. TURP and open prostatectomy for BPH should be relegated to the history books! I applaud the Mayo Clinic and its urologists for providing this invaluable procedure.
Please explain why with obstruction and most of gland removed urinary flow is improved with HoLEP, seminal liquifaction and penile erection functioning retained, but ejaculation is retrograde. Thank you.
Thank you for your comments on the Physician Update Video Blog. We have forwarded your request to Dr. Krambeck for comment. Best regards, Miriam Wuensch
Why retrograde ejaculation after HoLEP? What doctors in Phoenix, Arizona do HoLEP? Which doctors have done a lot of them? Will itr work on a prostate that is 150 cubic centimeters? What is the risk of incontinence? I would really appreciate answers to these questions. Thanks, Ken Boyd
Physicians at Mayo Clinic in Phoenix/Scottsdale perform HoLEP regularly. For more information about HoLEP, please visit http://www.mayoclinic.org/holmium-laser-prostate-surgery/about.html. For information about an appointment at Mayo Clinic (to discuss questions specifically related to your situation), please visit http://www.mayoclinic.org/holmium-laser-prostate-surgery/scttreatment.html.
Retrograde ejaculation occurs with any intervention that relieves bladder neck obstruction – thus it can even occur with some of the medications that improve urination. With normal ejaculation the bladder neck closes, preventing back flow of semen into the bladder. A surgical intervention or medication that helps with urination disables the bladder neck muscle. Subsequently, with ejaculation the bladder neck cannot close and the semen takes the path of least resistance – traveling into the bladder. Any procedure that completely relieves prostate obstruction with result in retrograde ejaculation.
2nd time asking for info re: retrograde ejaculation after HoLEP.
Please explain why this continues to be a problem w/ HoLEP, as this appears to be the only remaining surgical negative outcome this procedure has in common w/ TURP.
Less bleeding, fewer infections, shorter recovery time, reduced incontinence likelihood, possibility of improved erections – all positives and I assume an outcome of the very targeted nature of the surgery which minimizes nerve damage. So why continued retrograde ejaculation?
Thank you.
Thank you for your message. We cannot diagnose conditions, provide second opinions or make specific treatment recommendations through this correspondence, but if you wish to seek help from Mayo Clinic, please contact the appointment office at http://www.mayoclinic.org/patientinfo/appointments.html.
I am 59 year old ortho surgeon with BPH and had in office cyst for hematuria, no bladder tumor and ct of kidney normal and lab work fine. PSA 3.5 Slowly going up> Large prostate (not sure of actual volume) but they have recommended I see Dr Lingeman in Indy (I am from Evansville, In) Question: What happens if removed adenoma with HoLEP is found to be cancer – then what are choices – do you then do Davinci prostatectomy and remove capsule, or have you taken away that option by the previous hoLEP procedure. Thank you – Phil Stiver MD
Thank you for your message. We can’t make specific treatment recommendations through this correspondence, but if you wish to seek help from Mayo Clinic, please contact the appointment office at http://www.mayoclinic.org/patientinfo/appointments.html.
HoLEP does not prevent further treatment of prostate cancer. If a low grade, small volume cancer is identified at time of HoLEP then often times active surveilance is recommended. However, if a large volume or aggressive cancer is identified the patient can go on to have a successful radical prostatectomy – open or da Vinci.
Is HoLEP an option for people with very large prostates and low
grade prostate cancer with the idea of first reducing prostate
size so that focal therapies can then be used to treat the cancer.
Thank you for your message. Unfortunately, we cannot diagnose conditions, provide second opinions or make specific treatment recommendations through this correspondence. If you wish to seek help from Mayo Clinic, please contact the appointment office at http://www.mayoclinic.org/patientinfo/appointments.html.
Yes in certain cases this is an option. It would need to be reviewed on a case by case basis.
My urologist recently recommended my prostate removal for fear of long time retention and the associated problems. I found the laser info on the net and mentioned this to him. He said the Holep was for prostate cancer and small prostates and could only recommend either open reduction or TURP. All the info which I researched today helps me understand why he made this recommendation. I am making an appt. at Vanderbilt University for HoLep consult. Thanks for this and other sites.
I’m 60 years old. I have a prostate the size of a 25-year-old. I have been told I have a median lobe that needs to be removed. I’m not sold on the Green Light laser procedure. Can this median lobe be removed with Holep procedure? Thanks, Jon
Thank you for your message. We can’t make specific treatment recommendations through this correspondence, but if you wish to seek help from Mayo Clinic, please contact the appointment office at http://www.mayoclinic.org/patientinfo/appointments.html.
Although I do not have details of your case to render a second opinion, in general there is no upper or lower size limit to the HoLEP procedure. Thus, in the appropriate patient a median lobe can be removed with the HoLEP procedure.
In 2006 my husband was told he had prostate cancer and had radioactive seed implant. Now the doctors say he has obstructed prostate, they want him to have Holmium Laser Enucleation. My husband and I are confused. How can we get information to read about “Holep” to help us make a decision.
Thank you for commenting on the Physician Update Video Blog. You can read more about Holmium Laser Prostate Surgery (HoLEP) at http://www.mayoclinic.org/holmium-laser-prostate-surgery/. It may also be beneficial for you to contact the appointments department at Mayo clinic. Here is the online link, http://www.mayoclinic.org/patientinfo/appointments.html, which also includes telephone information.
I live in southern Utah,am 52 have a very large prostate. My doctor (knowing my reluctance to regular surgery) recomended HoLEP. The problem is my insurance (IHC) only covers Utah and emergencies. I am having a lot of problems now. This surgery sounds like my best bet. Any suggestions?
Thank you for your message. Unfortunately, we cannot diagnose conditions, provide second opinions or make specific treatment recommendations through correspondence. Please contact the appointment office at http://www.mayoclinic.org/patientinfo/appointments.html for more information about your options from Mayo Clinic.
I have a very enlarged prostate and would like to explore Holmium laser enucleation as a treatment. Are there any centers within a days drive that provide the procedure? Thanks for your help.
Thank you for your message. Unfortunately, we cannot diagnose conditions, provide second opinions or make specific treatment recommendations through this correspondence. You do not mention your location, but please contact the Mayo Clinic appointment office at http://www.mayoclinic.org/patientinfo/appointments.html for more information. If you haven’t already, learn more about holmium laser enucleation at http://www.mayoclinic.org/holmium-laser-prostate-surgery/.
I am not asking for diagnosis or medical advice. I simply want to know if there are any centers in Florida that have Holmium Lasers and do the enucleation procedure.
Physicians at Mayo Clinic in Jacksonville, Fla., do not perform HoLEP at this time. Physicians at Mayo Clinic in Phoenix/Scottsdale, Ariz. and Rochester, Minn. do perform HoLEP. We do not have information about referral to non-Mayo Clinic sites.
I understand you cannot diagnose or recommend treatment options within this forum. Although my question is driven by decisions I now need to consider, my question is not asking for an opinion with regard to my treatment but only about the possible viability of an approach to HoLEP to minimize damage to the muscle in the area of the bladder neck.
My prostate is 130 cm3. My local urologist is sharply focused on an open prostatectomy to the exclusion of all other procedures. Instead, I am considering HoLEP. I am very concerned about retrograde ejaculation (RE) and, due to this concern, I am avoiding any procedure until I no longer have a choice. My concern is based on RE experience associated with drugs such as Avodart etc. The intensity and pleasure associated with orgasms is unacceptably and significantly diminished when RE occurs. Therefore, I want to learn more about the HoLEP procedural technique and be satisfied aggressive efforts are possible to minimize the risk of this common problem. So, now my question.
Assume, albeit somewhat inaccurately, the prostate is approximately spherical. Then, a 130 cm3 sphere will have a diameter of 62 mm. In the area of the bladder neck only, is it reasonable to consider leaving a 6 mm (10% of diameter) “guard band” of undisturbed prostate tissue to help avoid insult and damage to the adjacent muscle? I recognize this small area would represent a relatively small part of the flow channel with higher than desired head loss (flow resistance) but, because this area is very small relative to the remaining internal area, almost all of which has been removed, the improvement in symptoms may still be significant. The risk of the small remaining prostate tissue growing and again requiring a follow-up procedure some number of years from now may represent an acceptable risk to the patient. I am guessing, in the aggregate, this risk is small. In the worst case it would not require action for a number of years, and might be well worth a consequential increase in the probability that normal or near normal sexual function can be maintained in all respects.
With regard to myself, the Mayo Clinic appears to be the institution of choice to consider for HoLEP. Although there is a single urologist in private practice within reasonable driving distance advertising HoLEP, I have a much higher confidence level using a well respected institution such as the Mayo Clinic. I live in Florida (Palm Beach area) and, if and when I decide to seek surgical intervention, I am hoping the pre surgical workups and later the follow-up can be done in Jacksonville (just a few hours driving distance). We would fly to Minnesota for the procedure.
Thank you for helping.
Thank you for your message. As you note in your request, our physicians cannot comment on your situation or confirm whether specific treatments may be helpful for you through this venue. Please contact the Mayo Clinic appointment office at http://www.mayoclinic.org/patientinfo/appointments.html.
Miriam, I was disappointed by your response. I specifically stated I was not asking for a diagnosis or treatment recommendation but only wanted some informed thoughts and discussion about methods that might be employed to minimize the risk of RE. I offered what appears, at least to me, to be a potentially viable approach to this challenge and just wanted to better understand if it has been used, if it has merit, or, if not, why. You cannot begin to know the high level of frustration of rarely being able to have anything more than superficial discussions with members of the medical profession. It seemed to me since this forum is apparently sponsored by the Mao Clinic, it is likely I will be Mao clinic patient, and there are obviously responses from knowledgeable individuals, I might have been lucky enough to get a meaningful response to my thoughts. Obviously I was wrong. It is possible, and even likely, for an individual to initiate a discussion about a medically related issue that is not directly related to diagnosing and treating an immediate problem. Sadly, this fact eludes most members of the medical profession. I probably will need the subject procedure sometime in the not too distant future and am trying to learn as much as I can about it. That certainly does not mean I am asking for treatment recommendations.
Unfortunately, retrograde ejaculation is a functional problem that cannot be avoided. Any procedure or medication that will correct outflow obstruction with result in retrograde ejaculation. The prostate and bladder neck are continuous. In order to deobstruct the bladder neck the bladder neck function is compromised; thus, it cannot close at time of ejaculation and the semen takes the path of least resistance – into the bladder. If a patient is not ready to accept RE then they should not have any procedure performed on the prostate.
After having reviewed the information I can access on the Internet concerning HoLep, I am convinced that this procedure is the best one for me. My ability to void naturally is severely compromised by a very enlarged prostate, leaving me with the only option, at this time, of self-catheterization, something I have been doing four times/day since June, 2011. Also, I have been on Finasteride and Tamsulosin since that time but appear to be getting no positive results from these drugs.
Logistically AND financially, Dr. Ramsey L. Kuo, who received his training at Methodist Hospital Institute… in Indiana, and now practices at St. Peter’s in Albany, NY, is the logical choice for me, despite my wishing it practical that I could go to Mayo. I know that doctors do not like to comment on their peers, so I don’t expect a meaningful reply. However, since I have but one body, I have to at least try to seek competent medical advice and comments for it.
As an aside and just out of curiosity, why isn’t the HoLep procedure available at Mayo in Florida, considering the high number of men over 60 there? It seems Mayo would be encouraging their own doctors to pursue the Holmium route in that state.
I would appreciate your response to two requests for general info about Mayo’s experience with the HoLEP procedure:
(1) How many HoLEP procedures are performed annually at Mayo MN? (I’ve seen on the website that about 150 are performed each year at Mayo AZ.)
(2) Can you also reveal which docs have the most experience with this procedure at each location? My sense from what I’ve read so far is that Dr. Krambeck in MN and Dr. Humphreys in AZ have done the lion’s share of the procedures, but I would like confirmation.
Scratch my first question. I see from the website that Mayo MN does about 200 procedures a year.
Thank you for your interest in HoLEP procedures at Mayo Clinic. For more information related to your particular situation, please contact Appointments at http://www.mayoclinic.org/patientinfo/appointments.html.